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Kokyu to Junkan Volume 45, Issue 9 （September 1997）

呼吸と循環 45巻9号（1997年9月発行）

Japanese English

症例

DDDペースメーカの植え込みにより左室内圧較差が著明に減少した肥大型閉塞性心筋症の1例 A Case of Hypertrophic Obstructive Cardiomyopathy Whose Left Ventricular Outflow Tract Gradient Was Markedly Reduced by Dual Chamber Pacing 竹中徳哉 ¹ , 土屋整也 ¹ , 岡田規雄 ¹ , 市川忍 ¹ , 新城博之 ¹ , 原田光徳 ¹ , 井関淳 ¹ , 平健司 ¹ , 山本原嗣 ¹ Tokuya Takenaka ¹ , Seiya Tsuchiya ¹ , Norio Okada ¹ , Shinobu Ichikawa ¹ , Hiroyuki Shinjo ¹ , Mitsunori Harada ¹ , Atsushi Iseki ¹ , Kenji Hira ¹ , Genshi Yamamoto ¹ ¹半田市立半田病院循環器科 ¹Department of Cardiology, Handa City Hospital キーワード：肥大型閉塞性心筋症 , 左室内圧較差 , DDDペースメーカ , hypertrophic obstructive cardiomyopathy , left ventricular outflow tract gradient , dual chamber pacemaker Keyword: 肥大型閉塞性心筋症 , 左室内圧較差 , DDDペースメーカ , hypertrophic obstructive cardiomyopathy , left ventricular outflow tract gradient , dual chamber pacemaker pp.907-911

発行日 1997年9月15日 Published Date 1997/9/15

DOI https://doi.org/10.11477/mf.1404901556

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　症例は58歳，男性．主訴は労作時呼吸困難．1991年僧帽弁閉鎖不全（MR）と肺高血圧を伴った肥大型閉塞性心筋症（HOCM）と診断され通院にて薬物療法をうけていた．1996年1月，労作時呼吸困難のため入院したが，聴診にて収縮期雑音を聴取．胸部X線写真で心胸郭比は60％，肺動脈の拡張と胸水貯留を認めた．心臓カテーテル検査にてペーシング条件を変えて圧測定を行った．左室内圧較差はコントロール時162mmHgであったが，P波同期型ペーシング（AV間隔100msec）時104mmHgと最低値を示し，肺動脈圧も低下し心係数も4.26l／min／m²と良好な結果が得られた．その後も，薬物療法のみでは症状は改善せず，永久ペースメーカの植え込みを行った．植え込み4日後に左室内圧較差は68mmHgと減少，心不全症状も改善し，MRは3度から2度へと改善した。DDDペースメーカの植え込みを行い，左室内圧較差の著明な減少，MRの改善と臨床症状の著明な改善を認めたHOCMの1例を経験したので報告する．

A 58-year-old man who complained of dyspnea on exertion was admitted to our hospital. He was diagnosed, since five years before, as having hypertro-phic obstructive cardiomyopathy complicated with mitral regurgitation and pulmonary hypertension. In the cardiac catheterization study, the left ventricular outflow tract (LVOT) gradient was measured during sinus rhythm and temporary pacing rhythm with vary-ing AV intervals. During p-wave synchronous pacing (VDD pacing) with an AV interval of 100 milliseconds as compared with that during sinus rhythm, the LVOT gradient was reduced from 162 to 104 mmHg and the main pulmonary arterial pressure was reduced from 120/55 to 90/35 mmHg, and the cardiac index was minimally reduced from 4.46 to 4.26l/min/m². Because he had failed to get clinical benefit by medica-tion only, and because he rejected surgical therapy such as open heart surgery, he was implanted with a dual chamber pacemaker. 4 days after implantation, re-study of cardiac catheterization was performed. The LVOT gradient was markedly reduced to 68 mmHg and the severity of mitral regurgitation was improved from degree 3 to degree 2. Following this, his clinical symp-toms were greatly improved.

Ours, therefore, is a case of a patient with HOCM wit mitral regurgitation and pulmonary hypertension who was implanted with a dual chamber pacemaker. Because his clinical symptoms were improved after implantation, it is suggested that the dual chamber pacing may be effective in the long-term reduction of symptoms and sudden death rate found among patients with HOCM.